Southborough Care Home

On this page

• Overview
• Learning culture
• Safe systems, pathways and transitions
• Safeguarding
• Involving people to manage risks
• Safe environments
• Safe and effective staffing
• Infection prevention and control
• Medicines optimisation

Safe – this means we looked for evidence that people were protected from abuse and avoidable harm. At our last assessment we rated this key question Good. At this assessment the rating has changed to requires improvement. This meant some aspects of the service were not always safe and there was limited assurance about safety. There was an increased risk that people could be harmed. The service was in breach of the legal regulation in relation to the way people’s medicines were managed. The service was previously in breach of the legal regulation in relation to safeguarding. Improvements were found at this assessment and the service was no longer in breach of this regulation.

This service scored 56 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The provider did not always have a proactive and positive culture of safety. Lessons learnt were not always actioned appropriately Whilst we found accidents/incidents and safeguarding concerns were shared with staff to prevent reoccurrence and improve safety, we found senior staff were not identifying concerns related to medicines either when administering medicines or auditing medicines. The service had a lessons learned process in place. Whilst we found concerns were being discussed the actions were not consistently being followed through. For example, an action included all staff cleaning the fluff from the tumble dryer duct, however we noted there were gaps in recording where staff were either not cleaning the fluff or failing to sign. People and relatives told us they were confident to speak up about any safety concerns and staff listened to them.

The provider worked with people and healthcare partners to establish and maintain safe systems of care, in which safety was managed or monitored. They made sure there was continuity of care, including when people moved between different services. The service had processes in place to ensure people were referred to appropriate services when needed. A pre-prepared hospital transfer form was contained within the care plan to ensure people’s important information was available if they needed to transfer to hospital. A staff member told us, “We always send a photocopy of medicine administration records (MAR) and their hospital passport in a red bag.” Relatives had no concerns about their family members transitioning between care services and told us they were kept informed.

The provider worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve that. Staff concentrated on improving people’s lives while protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. The provider shared concerns quickly and appropriately. People told us they felt safe living at the service. A person told us, “It is alright here, I feel very safe.” A relative said, “My [family member] is 100% safe.” Staff understood how to protect people from abuse and the reporting processes in place. A staff member said, “I would look for unexplained bruising, any marks, a change in personality, fear, not eating, anything unusual. I would report this to the manager or I would go to the local authority or CQC.” Systems were in place to safeguard people from abuse. The registered manager kept good oversight of all safeguarding referrals.

Risks assessments were completed and reviewed regularly, and these were used by staff to support people to reduce the risk of avoidable harm. Staff knew people well and understood how to support them safely. Personal emergency evacuation plans (PEEP) were in place and reviewed regularly within the care plan, however, we also found copies of these within fire records where it was not clear if they had been reviewed. This meant we were not assured the most up to date version would be available in the event of a fire. On day 2 of our assessment the PEEPS had been fully reviewed. Fire drills were taking place but did not contain any details about what had occurred and consisted of a date with staff names. More detail was needed to identify whether any mock evacuations or drills had taken place to confirm staff were confident in what to do if an emergency arose and if they had the time and resources available to evacuate safely. We observed staff used safe practice when supporting people with their mobility, including when using hoists and slings to transfer people. People and relatives told us they were fully involved in discussions about risk. A relative told us, “They involve us with any risks, we are waiting for a memory assessment. I was aware of when the speech and language team visited and I can phone for an update at any time.”

The provider did not always detect and control potential environmental risks. They did not always make sure equipment, facilities and technology supported the delivery of safe care. Some risks to the environment were identified including wardrobes secured to the wall using a method which did not fully mitigate the risk. Whilst window restrictors were in place some of the top openings on windows opened out quite wide. The provider took immediate action, and wardrobes were secured appropriately and window restrictors were ordered. The provider had undertaken improvement works at the service and some bedrooms and bathrooms were newly decorated and refurbished. People and relatives, we spoke with were happy with the safety of the environment.

There was enough staff to meet people’s physical needs and staff knew people well. We observed there was enough staff to respond to people and they did not have to wait for support, however, interaction was minimal and mainly task focused. This meant we were not assured peoples emotional and social needs were being met effectively. People and relatives were happy with the staff and felt they were suitably trained for their role. A person told us, “They help me with everything I need. They can be busy but they do come when I need them.” A relative said, “I think there is enough staff and they seem well trained.” Staff told us they were happy with the training provided. A staff member told us, “I think the training is very good. I am doing a diploma at the moment.” The provider had an effective recruitment and selection procedure in place.

People and relatives were positive about infection prevention and control measures in place. A relative told us, “The home is always clean when I am there, very clean. I have seen staff with gloves so I know they have them ready.” We observed that all areas of the home were clean and hygienic. The provider had policies and procedures in place to ensure people were protected from the risk of infection. Housekeeping staff were included on the staffing rota each day and completed cleaning checklists for all areas of the service.

Medicines were not always managed safely. During the assessment we identified a medicine which was being administered by staff and not signed for. A senior staff member undertook an investigation into why this had happened and why staff overseeing medicines processes had not picked this up. Other medicines were difficult to reconcile as some loose medicines were not dated so it was unclear when the medicines had started. The management team were not carrying out any reconciliation of medicines as part of the auditing process. Staff failed to ensure topical medicines were stored safely. We found topical medications that were accessible and unsecured in people’s bedrooms. This increased the risk of harm to people if used or ingested. Topical medicines charts contained numerous gaps in administration. The registered manager removed these topical medicines to the medicines trolley. During an observation we noted staff administering medicines in pairs. The staff member administering the medicine to people was not the staff member signing the medicine administration record. This was fed back immediately to the registered manager. Staff had received training on how to administer medicines safely. The management team had regularly assessed the staff’s competency. Medicine audits undertaken had not picked up the concerns found during the assessment so did not assure us these audits were effective.